The American Society for Radiation Oncology (ASTRO) provided recommendations on the use of radiation therapy and systemic therapy after surgery to treat patients with endometrial cancer, according to a newly updated clinical guideline published by Harkenrider et al in Practical Radiation Oncology. The guideline also considered the role of surgical staging and molecular profiling techniques in determining whether a patient should receive postoperative therapy.
Background
Standard treatment for endometrial cancer involves surgical removal of the patient’s uterus, cervix, fallopian tubes, and ovaries—with additional postoperative therapy indicated for patients with risk factors for cancer recurrence.
“Since ASTRO published its original endometrial cancer guideline in 2014, multiple research teams have published high-quality clinical trials on the usefulness of postoperative therapy for patients with different disease stages and risk profiles,” said guideline author Beth A. Erickson, MD, FASTRO, Professor of Radiation Oncology at the Medical College of Wisconsin and Chair of the guideline task force at ASTRO.
“For patients with an elevated risk of recurrence following endometrial cancer surgery, clinical trials consistently show that adjuvant therapy can improve outcomes,” Dr. Erickson highlighted, noting that “Our task force synthesized findings from these trials into recommendations for external-beam radiation, brachytherapy, and chemotherapy in the postsurgical setting, with a focus on multidisciplinary, patient-centered care.”
The guideline task force also considered new trials on the accuracy of surgical staging techniques and the increasing role of molecular profiling for endometrial tumors in guiding adjuvant therapy decisions.
“Researchers have identified several potential biomarkers for endometrial cancer and are now exploring whether these molecular markers can help determine which patients will benefit from adjuvant therapy,” explained lead guideline author Matthew M. Harkenrider, MD, Associate Professor of Radiation Oncology at the Loyola University Chicago Stritch School of Medicine and Vice Chair of the guideline task force.
The New Guideline
The new guideline included treatment algorithms for stage I and stage II endometrial cancers, stage I and stage II cancers with high-risk histologies, and stage III and stage IVA cancers. It detailed the recommended use of external beam radiation therapy, vaginal brachytherapy, and chemotherapy for patients with different risk profiles—as well as which patients should not receive adjuvant therapy. Key recommendations included in the new guideline are as follows:
- Based on a patient’s clinical-pathologic risk factors, radiation therapy may be recommended to reduce the risk of locoregional recurrence. The choice of external-beam radiation therapy vs vaginal brachytherapy in Federation of Gynecology and Obstetrics stage I endometrial cancer should depend on lymph node assessment and uterine risk factors. External-beam radiation therapy may be recommended for patients with stage I disease with high-risk features, stage II disease, or stage III or stage IVA disease.
- Systemic chemotherapy should be effectively sequenced with radiation therapy for patients with high-risk histologies and/or stage III or stage IVA disease to decrease the risk of distant and locoregional recurrence, respectively.
- When external-beam radiation therapy is indicated, the use of intensity-modulated radiation therapy with daily image–guidance may be associated with improved patient-reported outcomes and reduced side effects. (Recommendations in the guideline also outlined optimal radiation dosing, treatment planning, and delivery techniques based on the patient’s cancer stage and histology.)
- For surgical nodal staging, sentinel lymph node mapping may be recommended over pelvic lymphadenectomy—and the use of adjuvant therapy should be based on the patient's pathologic ultrastaging status.
- Molecular tumor profiling may be recommended and may be used to guide recommendations for adjuvant therapy.
The new guideline also acknowledged the negative impact of systemic racial disparities on outcomes for patients with endometrial cancer. While the guideline was focused on the medical considerations for treatment, the task force also wanted to recognize the complex nature of access to care for underserved patient populations.
Disclosure: ASTRO's clinical guidelines are intended as tools to promote appropriately individualized, shared decision-making between physicians and patients. None of the guidelines should be construed as strict or superseding the appropriately informed and considered judgments of individual physicians and patients. The updated guideline was developed in collaboration with the American Brachytherapy Society, the American Society of Clinical Oncology, and the Society of Gynecologic Oncology—and is endorsed by the Canadian Society of Radiation Oncology, European Society for Radiotherapy and Oncology, and the Royal Australian and New Zealand College of Radiologists. For full disclosures of the guideline authors, visit practicalradonc.org.
